Hyperbaric For Heroes

1
Hyperbarics For Heroes Application Mission

Mission Protocol

40 Daily sessions of hyperbarics have been identified by numerous doctors and institutions as the minimum protocol for the best outcome. Individuals not completing the Mission will experience regression that does not support what we are trying to accomplish.

40 Sessions (5 Sessions per week for 8 weeks Monday through Friday 3:45am).

20 Sessions of NeurOptimal (Every other day).

Pretest of RightEye, Hit Check, Self-Assessment, and Peak Flow Meter.

Daily test for self-assessment and Peak Flow Meter.

After completion of 20 hyperbaric sessions you will retest RightEye, Hit Check and Peak Flow Meter.

After completion of 40 hyperbaric sessions you will retest on RightEye, Hit Check and Peak Flow Meter.

30 days following completion of 40 hyperbaric sessions you will retest on RightEye, Hit Check, Self-Assessment and Peak Flow Meter.

After 6 months completion of 40 hyperbaric sessions retest for RightEye, Hit Check, Self-Assessment and Peak Flow Meter.

DISCLAIMER: We are a non-medical service, HIPAA does not apply. Your privacy is important to us. We will only share this information with staff members for consideration to our program.
2
Name* This field is required.
First Name
Last Name
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Email* This field is required.
example@example.com
5
Phone Number* This field is required.
Please enter a valid phone number.
6
Emergency Contact Name & Relationship* This field is required.
7
Emergency Contact Phone Number* This field is required.
8
What branch of the military? If deployed - When and where? If not military are you a first responder - When and where?* This field is required.
9
Please list any prescribed medications you are currently taking.* This field is required.
10
Please describe your medical diagnosis with supporting documentation.* This field is required.
11
What other symptoms and or injuries are you currently experiencing?* This field is required.
12
What are your recovery goals?* This field is required.
13
Please introduce yourself and provide our team with an explanation for why you would like to be considered for our program. * This field is required.
14
Do you currently use tobacco products?* This field is required.
Yes
No
15
Do you have any pending criminal charges?* This field is required.
Yes
No
16
Do you have a criminal record?* This field is required.
Yes
No
17
I would like to volunteer in the following areas.* This field is required.
Social Media
Graphic Design
Session Captain
Session Backup
Web-Development
18
I agree to arrive no later than 3:45 pm, Monday through Friday for 8 weeks.* This field is required.
Agree
Disagree
19
No non-prescription drugs in my system for 12 weeks prior/during our program.* This field is required.
Agree
Disagree
20
No alcohol in my system within 12 hours of my session.* This field is required.
Agree
Disagree
21
No strong odors good or bad, example going to the gym or strong perfumes and cologne are allowed in the chamber.* This field is required.
Agree
Disgree
22
Have you requested financial assistance from private or government organizations for funding of our program?* This field is required.
Yes
No
23
List at least 3 organizations you have/will contact or intend to contact for funding. * This field is required.
24
I will not use profanity, harsh language or loud and inappropriate conversation while at our facility.* This field is required.
Agree
Disagree
25
Your story could be beneficial in helping other heroes looking for a path to normalcy. Voluntarily sharing your testimony is encouraged, however soliciting others for why they attend is strictly prohibited.* This field is required.
Agree
Disgree
26
I have read, understand and agree with each of the terms and conditions outlined within the Hyperbaric for Heroes agreement. Repeated violations may result in the termination of agreement.* This field is required.
Agree
Disgree
27
The Hyperbarics For Heroes Mission provides each participant with $7000.00 of services that will address many challenges our veteran and first responders face. Our program will also prepare you to share your results with other veterans and first responders with the same struggles. Do you accept the mission?* This field is required.
YESNO
28
Signature* This field is required.
Powered by Jotform SignClear
Should be Empty: